Papers

What is a Root Cause?

"There are many “Root Cause Analysis” methods, procedures, and approaches on the market today.  None of these methods define “root causes.”  They say they do, but they do not.  No-one can agree on what a “root cause” is, and yet most people say they’re defining “root causes.”  Saying it differently, everyone says they do “Root Cause Analysis” these days, and yet everyone is doing something different.  Think about it…"

The Blame Virus

"Try taking notice of the damage being caused by our human tendency to “blame one another.”  Notice what happens when something goes wrong in your life, either at home, within your community, or at work.  Listen to what people say, and observe how they behave.  More importantly ...." 

Four Significant Problems with Root Cause Analysis

"Does your organization prefer to end its inquiries with system-type “causes?” If so, you will end-up wrapping yourselves into a tighter and tighter ball of checklists, procedures, and other rigid controls that are impossible for people to dwell in. Please do not go down this path. Learn from those who have. It is a dead-end, and often a fatal one."

The Revelations of Asphaliah

"Because of our human tendency to avoid questioning the  familiar,  the  author  of  this  paper was stymied when Safety and Risk were studied from a different perspective.  Asphaliah (phonetic  spelling) is the Greek word for safety.  Beginning with the Greek, and then exploring our human understanding of Safety and Risk from a variety of perspectives, this paper
draws some conclusions that are thought-provoking, and a bit disturbing."

New Century Same Humanity

"Having become recently immersed in the paradigms of Nuclear Power Generation, especially as they relate to “human  performance,” the author is somewhat aghast at the current trend in thinking:  “We have finally figured out how to operate our equipment without failure – now we’re going to do the same with the human.”  Human beings have always been the same, and will always be the same.  We make mistakes.  Interestingly, ..."